Geriatric care manager

Geriatric Care Managers:Geriatric Care Managers:Know When to Call ThemKnow When to Call Them

Presenter:

Moderators:

January 29, 2010

Vanessa R. Bishop, MSW, LICSW, CMC

Robert Bullock E. Ayn Welleford, PhD

This webinar presentation, including the slides, is not designed or intended as legal advice or counselnor is it intended to create an attorney-client relationship.

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DefinitionDefinition

A professional Geriatric Care Manager(GCM) is a health and human services specialistwho helps families who are caring for older relatives.The GCM is trained and experienced in any ofseveral fields related to care management, includingnursing, gerontology, social work, or psychology,with a specialized focus on aging and elder care(NAPGCM - www.caremanager.org).

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Need and Selection ProcessNeed and Selection Process

Elder care has become so complex, that amultidisciplinary team of experts is necessary tosuccessfully manage the total spectrum of needs ofelder clients. One of the essential players of this teamis the Care Manager.

The proper selection of each member of the careteam becomes critical. This is particularly true of theCare Manager.

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QualificationsQualifications

True or False:

Anyone regardless of their level of education andoccupational background can call themselves acare manager.

TRUETRUE

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QUALIFICATIONSQUALIFICATIONSLevel of Education

Degree Concentration

Licensure• Licensed Clinical Social Worker

• Registered Nurses (RN)

Work History

Certification

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Qualifications (cont.)Qualifications (cont.)

Level of EducationLevel of Education

• Bachelor’s, Masters, Post-Masters, Doctorate Degree?

• How will the componentseffectively and professionallybe managed if the caremanager does not have anappropriate level ofeducation?

Degree ConcentrationDegree Concentration

• What area is their degreeconcentration?

• Care managers with a background inpsychology, nursing, social work,public health administration andother fields related to human servicespecialization will be the mosteffective.

• Medical and mental healthbackgrounds are crucial whenhaving to prepare for guardianship,power of attorney, emergencyplacement and crisis management.

• Care Managers must know thetechniques and skills in determiningan individual’s capacity whenpetitioning for legal guardianship.

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LicensureLicensure

• Determines the ability toassess and determine anindividual’s mental,medical health andgeneral welfare

• A Licensed Clinical SocialWorker is particularlysuited to do this

Licensed Clinical SocialLicensed Clinical SocialWorker (LCSW)Worker (LCSW)

• Legally authorize toassess and determine thecognition, mood andbehavior of the client.

• Diagnose and treatmental illness withpsychotherapy

• Assist in guardianshipcases by assessing theindividual’s mentalcapacity using standardassessment tools.

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Registered Nurse (RN)Registered Nurse (RN)

• Have an extensive knowledge oftherapeutic interventions,medication therapy and medicaldiagnosis and are able to conducttreatments at the home site versusneeding to enter into a hospitalsetting.

• Can take treatment orders over thephone versus in the medical office.

• Are able to monitor a client’sphysical status and medicalmanagement, which is animportant component ofmanaging the total client/patientrelationship.

Work HistoryWork History

• Duration of experience in a relatedfield: months versus years.

• Service model: social workers,nurses, psychologist.

• Mission and/or philosophy orwork environment/setting

• Continuing education to maintainand expand ones knowledge base.

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Certification

• There is no specific license or degree forGeriatric Care Management.

• Certification exists for a Certified CareManager or Case Manager and can beused as indicators for competence.

• Eligibility requirements must be met.• College or advanced degree in a medical

or mental health related field.• Number of clinical supervision hours.• Number of years in the field.• Passing a certifying exam.

• Remember, certification is much differentthan a certificate.

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National Association ofNational Association ofProfessional GeriatricProfessional Geriatric

Care ManagersCare Managers

• No exam, howevereligibility requirementsmust be met

• Largely consists ofrequirements for care orcase managercertification.

• Has an extensive andgrowing directorythroughout the US.Directory also includestheir degrees, licensuresand areas ofspecialization.

The NationalThe NationalAssociationof SocialAssociationof SocialWorkers: AdvancedWorkers: AdvancedSocial Worker CareSocial Worker Care

ManagerManager

• No exam is required,however eligibilityrequirements mustbe met anddeterminedappropriate by thereview board.

National Academy ofNational Academy ofCertified CareCertified Care

ManagersManagers

• Conducts an examtwice year. Eligibilityrequirements mustfirst be met.

www.NACCM.netTel: 800-962-2260

www.caremanager.orgTel: 520-881-8008

www.socialworker.orgTel: 800-742-4089

SERVICESSERVICES

Care management iscomprised of manydifferent componentsand services.

Some care managersmight specialize in acertain area of caremanagement, e.g.Alzheimer’s andother memory relatedimpairments,consultation, acutemedical caremanagement andmuch more.

Comprehensive AssessmentComprehensive Assessment

Care PlansCare Plans

PlacementPlacement

Education ResponsibilitiesEducation Responsibilities

Psychotherapy and CounselingPsychotherapy and Counseling

AdvocacyAdvocacy

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ServicesServices(cont.)(cont.)

ComprehensiveComprehensive

AssessmentAssessment

Cognitive status

Medical history

Mood and behavior

Functional abilities

Activities of daily living

Home environment

Degree of informal and formal support networks

Finances

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Care PlansCare Plans

A requirement on each client

Assesses and determines problem areas andidentifies and implementsinterventions/approaches to reach care plan goals.

Is based on the initial and ongoing assessment.

Involve/engage the client in the care planningprocess.

Serves as a guide with ongoing monitoring andindicating necessary changes and modifications.

Is the basis of ongoing communication betweenthe family, client, lawyer, Care Manager and otherdisciplines.

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PlacementPlacement

Based on the assessment and comprised ofmany categories such as companion

care/home health services, adaptive devicessuch as grab bars, durable medical

equipment such as a walker, physical oroccupational therapies, an adult day

program or alternative residences such asassisted living

Extensive knowledge base in exploringfinancial options is also required.

The client and/or responsible party memberwill look to the Care Manager for information

on placement options and costs involved.

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EducationEducationResponsibilitiesResponsibilities

Family members, healthcareprofessionals and lawyers look tothe care manager as an educator.

Depending on the case the caremanager can educate one on

Alzheimer’s and other memoryrelated impairments, medicationtherapy, mental health, nutrition,Medicare disability, community

support and much more.

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PsychotherapyPsychotherapyandand

CounselingCounseling

As the elder’s degree of independence and capabilitiesdecreases and roles reverse, their thoughts, mood and

behavior declines.

Feelings of hopelessness, helplessness, role loss and socialisolation are some of the common thoughts and behaviors

exhibited in this population.

Can also impact loved ones.

Care managers can provide support by listening,understanding, empowerment and encouragement.

A licensed counselor or psychotherapist can intervenetherapeutically and provide individual, couples and family

therapy.

Enhances communication between the parties andimproves the quality of life for the client and their family.

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AdvocacyAdvocacy

Primary role of a GCM is to function as an advocate.

Respect the client’s right to self-determinationthrough client centered services.

Involve the client in the decision making process anddeveloping action plans.

We should also maximize the available services andbenefits whether it is from paid service providers

and/or unpaid help from family or friends

Ensuring competency and high ethical standards.

Providing efficient and cost effective services. Thisincludes determining if continued care management

is necessary.

Goal is to provide a plan of care that is continuouslysynchronized to the individual’s values.

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FAMILYFAMILYMANAGEMENTMANAGEMENT

When is Family Care at High Risk?

Too Much Stress on the Caregiver

Denial

Finances

Assuming Too Many Roles

Information Seeking Families

Open Line of Communication

Accessibility and Availability

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FamilyFamilyManagementManagement(cont.)(cont.)

When is theFamily at HighHigh

RiskRisk?

Caregiver is frail of elderly.

Takes on too many tasks nottaking into consideration their

own medical status andgeneral welfare.

Gaps or inconsistencies in theprovision of care

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StatisticsStatistics

In over 22,000,000 households Americans are performingservices whose economic costs is over $200 billion.

• Three-quarters of these Americans are women.• They use an average of 18 hours per week performing this

service• One in five spends over 40 hours per week.• 80% of long-term care is provided by family members at

home.• Most seniors age in place.• More than half of all caregivers help with at least one activity

of daily living and about one third help with at least three.

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Too MuchToo MuchStress on theStress on the

CaregiverCaregiver

FullFull--time employmenttime employment

Family of their ownFamily of their own

Strains in the family relationshipStrains in the family relationship

Feelings of guilt and angerFeelings of guilt and anger

The absence of active coping and managementstrategies can be of significant harm to the

client and caregiver.

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DenialDenial

Between the caregiver and theclient

Don’t agree with the situation orcondition

Unrealistic expectations

Conflicts about values between theparties

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FinancesFinances

Major impact on the role of thecaregiver.

Companion care services are costly.

Can cost up to several thousand permonth.

Not everyone has unlimited financialresources.

Determining when costly services are anecessity.

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AssumingAssumingtoo manytoo many

rolesroles

Role of the doctor, nurse, lawyer, social workeretc.

Making complex medical decisions

Tending to complex medical conditions

Ultimately jeopardizing and placing the client athigh risk.

This is why it is important to have a multi-disciplinary team.

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InformationInformationSeekingSeekingFamiliesFamilies

Lack of knowledge baseLack of knowledge base

Little to no expertise in makingLittle to no expertise in makingdecisionsdecisions

Looking to the care manager asLooking to the care manager asexpert and the guideexpert and the guide

Part of the client systemPart of the client system

Family is part of the supportFamily is part of the supportnetworknetwork

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Family Management (cont.)Family Management (cont.)

Client systemClient system

• Not just immediatefamily

• Friends, neighbors,distant relatives, powerof attorney and legalguardian

Health InsuranceHealth InsurancePortability andPortability and

Accountability Act ofAccountability Act of19961996

• Maintaining clientconfidentiality orprotected healthinformation.

• Disclosing informationonly to those who areauthorized.

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Family Management (cont.)Family Management (cont.)

Open Line ofOpen Line ofCommunicationCommunication

• Essential• Acting as a liaison

and/or mediatorbetween the disciplines

Accessibility andAccessibility andAvailabilityAvailability

• Attribute oftenoverlooked.

• Crisis and non-crisissituations.

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PlacementPlacement

When is Placement Appropriate? Inability to independently conduct their activities of daily living

Safety and quality of life is in jeopardy

Comprehensive assessment is a key component indetermining placement.

A key component in determining placement is the informationgathered in a comprehensive assessment. Key assessment tools aredemographics, psychosocial history, medical history, nutritionalstatus, cognitive and mental health status, functional abilities/statusand home safety.

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IndependentLiving:

One, two bedroom or studio

Amenities, full kitchen,transportation, housekeeping,

recreational outings or programs

Mild level of care, i.e.,administration of medication or

reminders

No 24 hour nursing care.

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AssistedAssistedLiving:Living:

One, two bedroom and studio. No full kitchen because at that point it isof question if the individual has to the ability to safely conduct meal

preparation.

Amenities, higher amount care, some medical services providedin house, i.e., dental, audiology some visiting doctors,

transportation, social and recreational programs.

Higher number of nursing staff and for longer periods duringthe day. M-Sun. Medical staff available in the event of an

emergency.

Some specialize in memory impairment and provide a specialcare unit.

Levels of care 1-4. 1= assisted with administration ofmedication, reminders, bathing lower body. 4= extensiveassistance with their activities of daily living, i.e., bathing,

dressing, feeding, meal preparation, transfers.

Important to look at long-term care nursing when this starts.

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Long-term carenursing:

When one requires 24-hour nursing care andcan no longer live safely in the community such

as AL with just custodial care. Requiresassistance from licensed nursing and medical

staff.

Many services provided, i.e., nursing, socialwork, dietitian, rehabilitation, visiting MDs,

podiatrist, audiologist, dental, ophthomology,and some specializing doctors, i.e, wound care.

Continuing CareRetirement

Communities:

Consists of Independent Living, Assisted Livingand long-term care nursing. Various entryrequirements and payer sources for each

residential setting.

A lifetime package is offered for those enteringinto IL, but there is no long-term care Medicaidfor those entering straight into long-term care.Alternative placement would have to be sought

after.

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ASSESSMENTASSESSMENTTOOLSTOOLS

DemographicsDemographics

Health StatusHealth Status

Mini Mental State ExaminationMini Mental State Examination(MMSE)(MMSE)

Nutritional StatusNutritional Status

Social HistorySocial History

Functional AbilitiesFunctional Abilities

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Demographics

Age

Gender

Location of residence

Language

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HealthHealthStatusStatus

Past and present medicaldiagnosis

Medical history

Current, progressive, terminal orend-stage illnesses

Medications

Allergies

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Mini Mental StateMini Mental StateExaminationExamination

(MMSE)(MMSE)

Basis for understandingcognition

Evaluates suspected memoryloss, language skills,

abnormal thinking process,calculation while assessingtheir mood, behavior and

appearance.

Used in determine capacityor capability in decision-

making process.

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NutritionalNutritionalStatusStatus

Appetite

Weight

Intake of food

Dietary restrictions

Swallowing

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SocialSocial

HistoryHistory

Interests and hobbies

Past and present residences

Occupations

Family support

Participation in the community

FunctionalFunctionalAbilitiesAbilities

AlternativeAlternativeResidentialResidentialPlacementPlacement

Geographic location

Degree of in-house and socialprograms and medical

services

Services in the community

Facilities’ assistance inaccessing these services

Out of pocket costs.Transportation is generally

out of pocket

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What PayerWhat PayerSourceSource

Does theDoes theFacilityFacilityAccept?Accept?

Key component in determining eligibility andaffordability.

Medicaid, Medicare, private pay, HMOs and long-term care insurance

Subsidies

Independent Living: subsidies, private pay

Assisted Living: subsidies, grants, private pay andsome long-term care insurance

Long-term care nursing: Medicare, Medicaid, HMOs,long-term care and private pay

Will determine coverage under health insurance andout of pocket expenses

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LongLong--termtermcare Medicaidcare Medicaid

Misconception of long-term careMedicaid

Must medically and financiallyqualify

Assuming one fully qualifies can bedangerous. At first glance you mightthink they will qualify but Delmarva,

KePRO or DMAS could determineappropriate for assisted living.

Have a care manager conduct amedical assessment to assist in

determining qualification.

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EligibilityEligibilityandand

admissionadmissionprocessprocess

Bed availability. An extensive waitlist can impact theadmission process. Census will determine if someone will

be accepted straight Medicaid or does a number ofmonths of private pay need to be considered.

Acuity level is also a factor. If nursing is already strainedbecause of the acuity level will they want to take another

patient placing the quality of care at risk?

Each residential facility, i.e., independent, assisted andnursing conducts a medical screen to determine

placement.

Financial applications are to be completed by the residentor responsible party member.

Decision making lies in the hands of the facility

Why I encourage that all of the eggs are not placed in onebasket. Have 2-3 facilities of interest determined.

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ConclusionConclusion

There are 26 million peopleworldwide with Alzheimer’sdisease (AD).

There are 5.2 million in theUnited States with AD and50% are undiagnosed.

The estimated direct andindirect US annual costs aremore then 148 billion.

Mil

lio

nP

eop

le

The United States has a significant problem now and it willintensify significantly in the future.

ConclusionConclusion (cont.)

To cover the total spectrum of needs in elder care,various disciplines will need to be involved. Moreimportantly, in depth expertise in each of thedisciplines, in particular that of geriatric caremanagement is required to assure a successful andsatisfactory outcome for those in or entering intotheir “golden years.”

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Documents

Geriatric care manager